Hesi Case Study Seizure Disorder

A man sitting across from Alanna starts having a seizure. His entire body is rigid, his arms and legs are contracting and relaxing, and he is making guttural sounds. Alanna yells for the nurse, who immediately comes into the waiting room.

1. Prioritize the nursing actions:

1st Safely move the client to the floor.
2nd Push the furniture away from the client.
3rd Remove people from the waiting room.
4th Assess the client’s blood pressure.
After initial interventions are implemented, the man continues to have a tonic-clonic seizure.

2. What action should the nurse implement next?

Note the time, duration, and type of seizure
After the man’s seizure activity stops he is moved to a private room. The client had a 3 minute seizure, has no apparent injuries and is oriented to name, place, and time, but is very lethargic.

3. Which intervention should the nurse implement?

Turn him to the side and allow the client to sleep
The nurse asks Alanna why she has been referred. Alanna reports that 2 weeks ago her roommate foundher passed out on the floor. Alanna states she could not remember what happened but thought it might be because she had not been eating right. Then, last week Alanna’s roommate found her making unusualsounds and noticed that her arms and legs were jerking. At that time she was taken to the emergency de-partment. She has her emergency room records and her past history medical records from her family healthcare provider.

4. To help determine why the seizure activity started, which question should the nurse ask Alanna?

“Have you ever had any type of head injury?
“Do you have a history of drinking alcohol?”
Alanna responds to the nurse’s questions, and then tells the nurse that someone has been talking to her about seizures and asked her if she had aura with her seizure. She asks the nurse, “What is an aura?”

5. Which response by the nurse is correct?

“It is a visual or auditory warning that the seizure is about to start.”
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The neurologist schedules Alanna for an electroencephalogram (EEG) and a magnetic resonance image (MRI) to help evaluate Alanna’s seizure disorder. The nurse discusses the tests with Alanna.

6. Which action should the nurse include in preparing Alanna for the EEG?

Instruct the client to refrain from consuming caffeine prior to the EEG
Alanna appears overwhelmed with all the information the neurologist discussed with her. She asks the nurse, “I don’t understand why the neurologist is ordering an MRI.”

7. Which statement by the nurse is the best response?A) “The test will rule out many possible causes of seizures.”

“The test will rule out many possible causes of seizures.”
The neurologist informs Alanna that no brain tumor, infection, or trauma was found but she did have seizure brain wave activity during the EEG. This brain activity is indicative of Epilepsy. The neurologist
prescribes phenytoin (Dilantin), an anticonvulsant, to help prevent the seizure activity. The clinic nurse teaches Alanna about the medication, its side effects, and the need to take it every day.

8. Which statement indicates that Alanna understands the client teaching?

“I must brush and floss my teeth after every meal.”
Medication does not ensure that the client will not have seizures. In some instances medication dosage may need to be adjusted or the client may need another medication.The nurse continues to teach Alanna about the newly prescribed anticonvulsant medication.

9. Which instruction should the nurse include in the teaching session?

Avoid hazardous tasks until the drug has been regulated.
During the teaching session, Alanna shares with the nurse that she is very scared because she really doesn’t remember having the seizure. She states that she had never seen someone with a seizure until the other day in the neurologist’s office. Illness has never been part of her life and she doesn’t feel sick now.

10. Which response by the nurse is most therapeutic?

“This is all new to you, and you must be frightened. Let’s talk for awhile.”
Alanna shares that she is worried about being able to have children. She doesn’t have a boyfriend right now but someday wants to get married and raise a family.

11. The nurse’s response should be based on which scientific rationale?

Epilepsy does not prevent women from having children.
Education is the key to treating epilepsy. The office nurse teaches Alanna about how to reduce the inci-dence of seizure activity and how to promote safety during a seizure.

12. Which health promotion activity should the nurse discuss with Alanna?

Learn to identify seizure triggers.
Alanna tells the nurse that she was on her “period” or getting ready to start her “period” both times she had a seizure. She shares with the nurse she is really worried about having a seizure the next time she menstruates.

13. How should the nurse respond?

“Your menstrual cycle can cause seizure activity due to hormone levels.”
14. Which statement by Alanna indicates that teaching provided by the nurse has been effective?
“I will carry a Medic Alert band at all times.”
Two months after being diagnosed with the seizure disorder, Alanna calls the office and tells the nurse that her job’s supervisor has informed her that she is going to be let go because of her seizure disorder. Alanna is very upset and tells the nurse that she has been working at the same department store since she was 18-years-old.

15. Which statement reflects that the nurse understands the legal ramifications of the employer’s action?

“According to the Americans with Disabilities Act, your employer cannot terminate you.”
16. How should the nurse respond?
“You need to contact the Department of Transportation to find out the state laws.”
Alanna, her roommate, and her parents decide to attend an epileptic support group meeting that is held monthly at the local hospital. The topic for tonight is leisure activity and living with epilepsy. A clinical
nurse specialist is the guest speaker for the group. One of the group members asks the nurse, “Is it okay for me to swim at the local YMCA?”

17. Which statement is the nurse’s best response?

“Someone should be with you that knows what to do if you have a seizure.”
Another member of the group asks if there are any activities that should be avoided.

18. How should the nurse respond?

“It really depends on how well your epilepsy is controlled.”
When the group meeting is over, Alanna privately asks the nurse, “When is the best time to tell a potentialboyfriend I have a seizure disorder?”

19. If the nurse believes in the ethical principle of veracity for the client, how should the nurse respond?

“You should tell him the truth on the first date so he will know.”
An Emergency OccursThree weeks after the phone call to the office nurse, Alanna is transported to the emergency room by an ambulance, accompanied by her roommate. Her roommate states, “She was watching television and had a seizure. As soon as the first seizure stopped, she started having another seizure, so I called 911.” Alan-na is lying on the stretcher with her eyes closed but there is no seizure activity at this time.

20.Which intervention should the nurse implement first?

Ensure suction equipment is at the bedside.
She has intravenous fluids of 5% Dextrose in Wa-ter (D5W) infusing at 100 ml/hour in the left forearm. The emergency room physician prescribes phenytoin (Dilantin) 25 mg intravenous push.

21. Which action should the nurse implement?

Dilute the medication and flush the tubing before and after with normal saline.

Dilantin is not compatible with any fluid except normal saline; the nurse should flush the IV before and af-ter with normal saline only.

An hour later, Alanna is awake and alert. She does not remember what happened but remembers hearinga buzzing sound. The next thing she remembers is waking up in the emergency room.

22. Which question is most important for the nurse to ask Alanna?

“Have you been taking your medication regularly?”

Since the therapeutic Dilantin level is low, the nurse may infer that Alanna has not been taking her medication as prescribed. However, the nurse needs to clarify this inference, and then determine the reason before taking further action. It is important to question the client in a non-threatening manner to obtain theneeded information, which helps establish a therapeutic relationship.

Alanna is admitted to the medical unit and her parents arrive a few minutes later. She is drowsy but arouses easily to verbal stimuli.

23.Which intervention should the nurse implement?

Pad and elevate the side rails of Alanna’s bed.

Alanna is at high risk for injury because of her recent seizure activity. Protecting her from injury by elevat-ing and padding the side rails helps address Alanna’s safety needs.

Alanna’s mother tells the nurse that neither she nor her father have ever seen Alanna have a seizure. They have read all the information on epilepsy and have talked to Alanna and the neurologist about the seizures but are very worried about their daughter. The mother tells the nurse, “I don’t think I would know what to do if I saw her have a seizure.”

24. How should the nurse respond?

“The most important thing is to keep her from injuring herself.”

Nothing can stop the seizure once it starts. Protecting the client from injury is the most important action to take.

Alanna’s primary nurse realizes that Alanna is of the Jewish faith and wants to provide culturally sensitive nursing care during her hospitalization.

25. Which statement reflects that the nurse is sensitive to Alanna’s cultural needs?

“Tell me about the type of Jewish teachings you practice.”

Many people of the Jewish faith practice different teachings, some more Orthodox and some more liberal.Therefore the nurse needs to know about Alanna’s practices to help meet her cultural needs.

Alanna later tells the nurse that she and her family do follow a kosher diet. The next morning, Alanna’s parents arrive at the nurses’ station with a kosher breakfast for Alanna, which includes a bagel, scrambledeggs, and a glass of orange juice. Alanna has no prescribed dietary restrictions.

26. What action should the nurse take?

Return the tray provided by the hospital and ask the parents if they would like to take the meal they provided to Alanna’s room.

This action supports Alanna’s cultural food preferences and also ensures that the kosher foods do not come in contact with non-kosher foods, and are not inadvertently served on dinnerware used for non-kosher foods.

Alanna is discharged from the hospital after 2 days. Her Dilantin level is 10.4 mcg/ml after receiving intra-venous Dilantin. Alanna’s neurologist is changing Alanna’s anticonvulsant from Dilantin to valproic acid (Depakote) to reduce possible side effects and increase her compliance with medication administration.

27. Which action should the nurse include when providing discharge teaching regarding the new medication?

Discuss with the client the importance of having liver function tests while on this medication.

This medication is heptotoxic so liver function tests are monitored at follow-up visits.

Prior to Alanna’s discharge the nurse evaluates the client teaching provided during this hospitalization.

28. When planning care, which client teaching goal is most important when determining Alanna’s understand-ing? The client will

Describe five strategies to prevent seizure activity.

A correct description of the needed information is the best way to evaluate if teaching was effective. Re-member goals must be measurable.

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